Temporomandibular joint

1. TMJ ANKYLOSIS
DR ANKITA RAJ (PROFESSOR)
DEPT OF ORAL AND MAXILLOFACIAL SURGERY

2. CONTENTS
HISTORY
ETIOPATHOGENESIS
OSA
CLASSIFICATION
CLINICAL FEATURES
RADIOLOGICAL FEATURES
AIMS AND OBJECTIVES
INTUBATIONS
SURGICAL ANATOMY
PROCEDURES
SOFT TISSUE INTERPOSITIONAL MATERIALS
HARD TISSUE RCU RECONSTRUCTION
TOTAL TMJR
SECONDARY DEFORMITIES

3. III. INTRODUCTION

4. • Humphrey in 1984 first performed condylectomy
• Esmarch was said to be the first surgeon to perform
an osteotomy for treating mandibular ankylosis in
1851.
• Abbe introduced the GA technique in 1880.
• Risdon in 1934 used interpositional material.
• Gillies first described TMJ reconstruction with
costochondral graft
HISTORY

5. • Pickeril (1942) : used cartilagenous graft in TM
Joint ankylosis
• Papageorge and Apostolids (1999) : published
report on simultaneous mandibular distraction
and gap arthroplasty in T.M.J. Ankylosis.
• Yonehara (2000) : reported gradual distraction
helped to recreate harminous soft tissue and
bony elongation of hypoplastic mandible.
HISTORY

6. Trauma
( Forceps delivery , injury involving neck of condyle )
Extravasation of blood in joint space
Clot organization
Calcification and obliteration of joint space
Ankylosis (extracapsular )
Immobilization (> 4 weeks )
Disc undergoes progressive destruction
Flattening of the glenoid fossa & thickening of the condylar head
Ankylosis (Intraarticular )

8. Dual effect of mouth opening on new bone formation in recent condylar trauma

9. Importance of OSA
• Retruded mandible causing
narrowing of PAS
• Mechanical obstruction to
respiration: Apnoea Hypapnoea
episodes,
reduction in the mean oxygen
saturation levels and secondary
cardiac and respiratory problems
• Ankylosis release without
advancement of mandible:
worsening of already compromised
airway
• Mouth opening exercises can lead
to upper airway collapse

10. CLASSIFICATION

11. Juxta-articular ankylosis

12. II.Topazian’s – true ankylosis
• Type I– Affects the condyle only
• Type II – Intermediate
• Type III – Entire ( condyle , coronoid , cranial base )

13. III. Rowe’s (according to the tissue involved )

19. Shanghai Ninth People’s hospital classification of TMJ ankylosis based on Coronal CT

20. Yan and colleagues (2014)
Based on its development, ankylosis can be classifed into three phases:
• Fibrous-chondral phase demonstrating fibrous tissue and
chondrocytes occupied the joint gap
• Chondral-calcified cartilage phase manifesting abundant
chondrocytes, cartilage matrix, and neo-formative endochondral
ossification in the joint space
• Bone-cartilage phase showing compacted bone bridge in the lateral
joint gap and cartilage in the medial joint gap

21. Restricted oral opening
Difficulty in mastication
Protrusive movements absent
on involved side
Pain usually absent
Diagnosis

24. RADIOLOGICAL FEATURES
Ankylosed Mass
OPG
Elongated coronoid process

25. (Yan et al. Head & Face
Medicine 2014, Current
concepts in the pathogenesis
of traumatic
temporomandibular joint
ankylosis)
Yan et al.
-enlarged condyle,
thickened temporal
bone, excessive bone
formation, and a
radiolucent zone in the
bony fusion area

26. CT SCANS

27. • Preoperative Assessment
Investigations
1. Detailed history, complete clinical
examination, professional
photographs, for documenting the:
(a) Age of onset of ankylosis
(b) Type, duration, and extent of
ankylosis
(c) Type of joint injury or infection
(d) Maximal interincisal opening
(e) Dental characteristics and occlusion
(f) Type of facial deformity
(g) Previous surgery

28. 2.Routine hemogram and pre-op major investigations
3. Radiological examinations for evaluation of extent of ankylotic mass, discrepancy of jaws, and treatment
planning
(a) Orthopantomogram:

30. (d) Facial CT scan:

33. The standard components of the polysomnogram include the
• electroencephalogram (EEG),
• electro-oculogram (EOG),
• electromyogram (EMG) and
• electrocardiogram (ECG, leadV2)

34. 3D stereolithographic
models printed, with
the help of CT scan,
may be used in
treatment planning.

35. TREATMENT
AIMS AND OBJECTIVES

36. Surgical technique selection depending on following:
• Age of onset of ankylosis
• Extend of ankylosis
• Unilateral/bilateral involvement
• Associated facial deformity

42. Protocol for release, Interposition & RCU
reconstruction
• Kaban’s Protocol for Management of Temporomandibular Joint
Ankylosis (1990)
I. Aggressive resection of the ankylotic segment
II. Ipsilateral coronoidectomy
III. Contralateral coronoidectomy when necessary
IV. Lining the joint with temporalis fascia or cartilage
V. Reconstruction of the ramus with a costochondral graft
VI. Rigid fixation of the graft
VII. Early mobilization and aggressive physiotherapy

43. II. Kaban’s modified protocol for management of Tmj Ankylosis in children
(2009)
a) Aggressive excision of fibrous and/or bony mass
b) Coronoidectomy on affected side
c) Coronoidectomy on opposite side if steps 1 and 2 do not result in MIO of 35 mm or
to point of dislocation of opposite side
d) Lining of joint with temporalis fascia or the native disc, if it can be salvaged
e) Reconstruction of RCU with either DO or CCG and rigid fixation
f) Early mobilization of jaw; if DO used to reconstruct RCU, mobilize day of surgery; if
CCG used, early mobilization with minimal intermaxillary
fixation (not > 10 days)
g) Aggressive physiotherapy
(Kaban, Bouchard, and Troulis. Management of Paediatric TMJ Ankylosis. J Oral
Maxillofac Surg 2009.)

45. CONDYLECTOMY

47. A2 PREOP
A3
LATERAL ARTHROPLASTY
A2 POST OP

54. They have stated that the intermittent compressive forces of the joint may act as a negative influence on the growth and
also explained the fat tissues are maintained within the joint space itself

57. RCU RECONSTRUCTION IN
TMJ ANKYLOSIS

58. After release of
ankylosis
Are we reconstructing
RCU ?
AHI:69.7

60. Goals
Improvement of mandibular form and function
B/l cases: Restoration of height of ramus
Prevention of further morbidity
U/l cases: Decrease lateral deviation and improve stability
Normalization of occlusion

61. Materials for reconstruction
Autogenous grafts :
Derived from vicinity
- Ankylotic Mass
- Coronoid Process
- Posterior Border Ramus Osteotomy
VRO
LRO
Derived from distant site
- Costochondral Graft
- Sternoclavicular Graft
- Iliac crest
- Fibula Graft
- Metatarsal Graft
Transport Distraction
Alloplastic grafts :
- Hydroxyapatite collagen block
- Total TMJ Replacement System
Lateral Arthroplasty

62. Materials for reconstruction
Autogenous grafts :
Derived from vicinity
- Ankylotic Mass
- Coronoid Process
- Posterior Border Ramus Osteotomy
VRO
LRO

63. Materials for reconstruction
ANKYLOTIC MASS

64. Ankylotic Mass
 3 Adults
 no reankylosis at 12 months F/U
R. Gunaseelan: IJOMS 1997
H/p - Bony trabeculae having marrow elements, focal fibrosis,
collagenization
- normal cartilage calcification
Nanda Kishore Sahoo, J Craniofac Surg 2012

65. Resected ankylotic mass
Post-op OPG with graft
Recontoured graft fixed
with 2, 4mm screws

66. Surgical considerations in rcu reconstruction
Final position of neocondyle in glenoid fossa
Determined by position of ramus
Occlusion
Length of graft trimmed accdg to original height of ramus
Fixation of graft

67. MERITS
• No donor site morbidity
• Recycling of bony ankylotic mass
• Dense bone with smooth cortical
surface
DEMERITS
• Not always possible to resect
ankylotic mass in bulk without
risking internal maxillary artery
Vishal Bansal, BJOMS 2016

68. Materials for reconstruction
CORONOID PROCESS

69. Coronoid Process Pedicled on Temporalis
Muscle
• Temporalis stripped off except anterior portion attached to tip of coronoid
Yiming Liu, OOOO 2010
 Less Resorption
 Less decrease in ramus height
 Less deviation in mouth
opening

72. Coronoid Process – Potential for continued growth
- Boon or bane?
- Effect on mouth opening?

73. MERITS
• Harvested safely & easily
• Size, shape, & thickness
suitable for reshaping
DEMERITS
• Nonpedicled – chances of
resorption
• If ankylosed segment
also involves coronoid &
is removed in pieces,
then cannot be used
A. Khadka, J. Hu: Int. J. Oral Maxillofac. Surg. 2012

74. Materials for reconstruction
POSTERIOR BORDER RAMUS
OSTEOTOMY

75. Posterior border Ramus Osteotomy
First described by Markowitz in 1989
Traditional approach – gap or interpositional arthroplasty
Reconstruction with non pedicled grafts
Resorption of graft
Decrease in height of ramus Deviation on mouth opening
Facial asymmetry
Y. LIU,Int. J. Oral Maxillofac. Surg. 2011

77. Materials for reconstruction
VERTICAL RAMUS
OSTEOTOMY

78. Vertical Ramus
Osteotomy
• Osteotomy of
posterior border
for condylar
hypertrophy
• Medial pterygoid
attachment
prevents resorption
Y. LIU,Int. J. Oral Maxillofac. Surg. 2011

79. Total VRO cut Sliding Recon Contouring &
fixation

80. Materials for reconstruction
L RAMUS OSTEOTOMY

81. L-shaped
Ramus Osteotomy
• Modification of VRO
• Osteotomy is
performed 1.0 cm
above mandibular angle
Y. LIU,Int. J. Oral Maxillofac. Surg. 2011

82. L- SHAPED RAMUS OSTEOTOMY

84. Materials for reconstruction
VRO V/S LRO

85. VRO vs Lro
 Height of ramus
 Difference in indication: antegonial notch

86. MERITS
• Avoids resorption, infection, donor-site
complications
• Adequate size & shape for new condyle with
same histologic characteristics
• less decrease in height of ramus, less
deviation
• Resolves problems of secondary mandibular
asymmetry due to Re- restoration of growth
spurts (moss functional matrix theory)
DEMERITS
• Cannot be used if width &
height of ramus is inadequate
• Lack of inherent growth
• Extra incision
Y. LIU,Int. J. Oral Maxillofac. Surg. 2011

87. Materials for reconstruction
Autogenous grafts :
Derived from vicinity
Derived from distant site
- Costochondral Graft
- Sternoclavicular Graft
- Iliac crest
- Fibula Graft
- Metatarsal Graft

88. Materials for reconstruction
COSTOCHONDRAL
GRAFT

89. costochondral Graft
• Popularized by Poswillo, 1987
• Replaces vertical bony portion of ramus & cartilage of condyle
• Variables:
A. Which ribs
B. How much cartilagenous cap?
C. How to fix?
D. ? Post op IMF
E. Resorption Vs Hypertrophy
N. R. Saeed. IJOMS. 2003

90. Harvesting of CCG
A) LENGTH OF GRAFT & CARTILAGENOUS CAP:
Vishal Bansal, BJOMS 2016
Cartilaginous cap - 2-4mm in length
Graft taken from - 4th or 6th rib
H. Sharma et al, JMOS 2015
Cartilaginous cap - 4–5 mm.
Graft taken from - 5th or 6th rib.
Samman , IJOMS 1995 & Link JO, JOMS1993
5 mm cap – linear overgrowth of CCG unit

91. B) HOW TO FIX:
- Extraorally with screws/ miniplates
- Extraorally with shaving of ramus
- Intraorally
C) POST OP INTER-MAXILLARY FIXATION:
- No clinical difference in outcome b/w early release
v/s IMF
Ahmed M.M. Medra, BJOMS 2004,

92. Meticulous dissection of periosteum & perichondrium
Retaining intact periosteum & perichondrium at CC junction
Harvesting alternate ribs
- Prevents pain & pleural tear
Sectioning chondral part before osseous part
- Reduces fracture costochondral junction
3-4 mm of chondral portion
-helps to avoid overgrowth
A. Khadka, J. Hu: Int. J. Oral
Maxillofac. Surg. 2012
To maximize chance of survival of gra

93. D) RESORPTION OR HYPERTROPHY:
Jean Salash, JOMS 2015
Out of 72 cases
• Excessive growth on treated side - 54%
• Growth equal to that on opposite side occurred - 38%
Peltomaki, JOMS 2002
• Inability of CCG to adapt to growth velocity of new environment

99. • Biological
compatibility,
workability &
functional adaptability
• Growth potential
• Morbidity of donor site
• Un predictable growth
pattern
• Contraindication -
Recurrent Ankylosis
MERITS DEMERITS

100. Materials for reconstruction
STERNOCLAVICULAR
JOINT

101. Sternoclavicular
Graft
Sternoclavicular joint & TMJ are similar anatomically & physiologically:
• Head of clavicle contains layers of cartilage
• Growth centre
Limitations
- Unacceptable location of surgical scar
- Donor-site complications:
• Damage to great vessels
• Instability of clavicle
• Shoulder instability
• Clavicle fracture
Denials S,JOMS 198

103. Materials for reconstruction
ILIAC CREST

105. Iliac
Crest Graft
• Chondro-osseous graft – full thickness piece of iliac crest including
overlying cartilage layer
• Vertical growth pattern of ilium is converted in graft to multidirectional
pattern
• Donor-site complications:
 Altered gait
 herniation of abdominal contents
 ilium fracture
 peritonitis
KUMMOONA 1986 : No cases of reankylosis in 18months
Kummoona, J Maxillofac Surg 1986

106. Materials for reconstruction
FIBULA GRAFT

107. Fibula Graft
• Tubular in shape, densely cortical
• Easily adapted to passively fit in glenoid fossa
• Vascularized & Non -vascularized
LIMITATIONS :
• Lacks articular cartilage
• Donor-site morbidity: great toe flexion contracture, ankle
stiffness & weakness and numbness of lateral side of leg

108. Materials for reconstruction
METATARSAL GRAFT

109. Metatarsal
Graft
• Provide good supply of articular cartilage combined with up to 7 cm of
vascularized bone
• Smaller than TMJ, so it easily fits within confines of glenoid fossa
• Intact epiphysis in transplanted MTP joint contains epiphyseal growth
plate

110. Materials for reconstruction
TRANSPORT DISTRACTION

111. Transport Distraction Osteogenesis
STUCKI-MCCORNICK – First to apply DO
in 2 cases of tumour involving condyle in
1997
Bone regeneration at trailing edge of
transport disc
Bridging defect without bone graft
Advantage : formation of cartilaginous
capsule at end of transport disc
Divya Mehrotra, J Oral Biol Craniofac Res. 2012
Harry C,J Oral Maxillofac Surg
66:718-723, 2008

112. Transport Distraction Osteogenesis
Indications:
 Reankylosis cases/ mutiple
operations
 Thick scar tissue impedes
vascularity - Poor implant
survival
Reverse L
corticotomy from
sigmoid notch to 10
mm from angle
Distractor secured on pins
in predetermined angle
Muralee Mohan C. Nitte University Journal of Health Science 2014

113. DIVYA

114. preop
Post distraction
6 mos f/u

116. Sternoclavicular joint
TDO

118. MERITS
• Proportional & harmonic
modification of muscles &
surrounding soft tissues
• Reestablishing correct
function of soft & skeletal
tissues
DEMERITS
• lengthy procedure, compliance
• Pin-tract, bone infection,
psychological problems
• Vigorous post op PT- pseudo
arthrosis at osteotomy site
• Long term?
Divya Mehrotra, J Oral Biol Craniofac Res. 2012

119. Materials for reconstruction
HYDROXYAPATITE COLLAGEN BLOCK

120. Hydroxyapatite Collagen Block
• Pre-shaped Hydroxyapatite collagen block with PRP
• Carriers for PRP provide scaffold for neocondyle formation
10 cases – 18 months f/u
Disadvantages:
- wear or failure of material
- Giant cell foreign body reaction
- Displacement or fracture of block

121. Materials for reconstruction
TOTAL TMJ REPLACEMENT SYSTEM

122. Mercuri et al. specifed the indications of TJR
• Recurrent fibrous or bony ankylosis not responsive to the
modalities of treatment which have been applied
• Failed (bone and soft) tissue grafts
• Loss of vertical mandibular height and occlusal relationship due
to bone resorption, trauma, developmental abnormalities, or
pathological lesions
• Severe inflammation of TMJ involving damage to its structures
and lack of response to other treatment methods.

123. TOTal TMJ
Replacement
• ‘‘Ball & socket’’ type prosthetic joint similar to a
hip implant.
Initially fossa-only prostheses/
only prosthetic condylar part
( unacceptable bone resorption and
prosthetic device failures)
Total Joint replacement

124. Total TMJ Replacement
Effectively deals with
distorted anatomy
No vascularity issues –
recurrent cases
No need for second surgical
site
Release & asymmetry
correction together
L.M. WOLFORD,IJOMS 2003

130. Complications
Methods of RCU
reconstruction
Reankylosis Resorption Deviation upon mouth opening Occlusal Discrepancy
n N % n N % n N % n N %
Ankylotic mass 2 22 9.09 4 22 18.18 6 22 27.27 5 22 22.72
Coronoid 3 36 8.33 4 36 11.11 4 36 11.11 3 36 8.33
CCG 6 34 17.64 9 34 26.47 15 34 44.11 11 34 32.35
VRO & LRO 1 49 2.04 0 49 0 0 49 0 0 49 0
Total 12 141 8.51 17 141 12.05 25 141 17.73 19 141 13.47
Note: (n = Number of events, N =Number of joints per subset

131. Situations TECHNIQUE JUSTIFICATION
1. <8 years a)With facial asymmetry CCG/SCJ +/- eventual
high condylectomy
• Potential for growth
• Treat overgrowth like
condylar hypertrophy
b)Without facial
asymmetry
Coronoid Graft • Potential for growth not
required
• Cannot do ramus osteotomy
because of ramal width
2. > 8 years a)With prominent
antegonial notch
Vertical ramus
Osteotomy
• Reduces antegonial notch
b)Without prominent
antegonial notch
L-shaped ramus
Osteotomy
• Adequate ramal size
• Maintains height of ramus
3. Re
ankylosis
a)Child Ramal Transport
distraction
• Free graft will not take in
scar tissue
• Alloplastic joint will not grow
b)Adult TJR • Best option for scarred tissue

137. THANK YOU